Entrapment of pacemaker leads in bone

A 71-year-old man underwent right pectoral dual-chamber pacemaker implantation for sinus node dysfunction in 1991. He was severely injured in a motor vehicle accident in February 2004, with prolonged hospitalization for fractures and internal injuries. In December 2004, he underwent pacemaker generator replacement for battery depletion, as well as a new atrial lead insertion for old atrial lead fracture, presumably a consequence of the accident. Two weeks later, he had dehiscence of the wound and was referred to our institution for a pacemaker system extraction because of pacemaker pocket infection. The new atrial lead was easily removed, but the 13-year-old leads required formal extraction. A laser sheath was sequentially advanced over each old lead, but despite laser activation at a presumed site of scar binding near the shoulder, forward progress beyond the inferior clavicular margin was impossible. Surgical dissection was performed down the leads to identify the problem, until the clavicle was reached. The leads were found to be entrapped in bone at the site of a well-healed clavicular fracture (Figure 1). A large clamp was used to break off the inferior bridge of bone (Figure 1, arrow), freeing the leads. Laser lead extraction then proceeded smoothly with complete removal of both old leads. On review of the preprocedural chest radiograph (Figure 2), the old atrial and ventricular leads (between arrowheads) could be seen as they passed through the inferior portion of the clavicle at the site of the old fracture (asterisk). The more recently implanted atrial lead (arrow) took a more caudal course, entering the subclavian vein beneath the clavicle. The patient recovered quickly from the extraction procedure, and a new pacemaker was implanted on the contralateral side after a course of antibiotics.